1306930599 NPI number — LISA ANNE SCOTT NNP

Table of content: LISA ANNE SCOTT NNP (NPI 1306930599)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1306930599 NPI number — LISA ANNE SCOTT NNP

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
SCOTT
Provider First Name:
LISA
Provider Middle Name:
ANNE
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
NNP
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
FATH
Provider Other First Name:
LISA
Provider Other Middle Name:
A
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1306930599
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
09/19/2019
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
5855 BREMO RD STE 100
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
RICHMOND
Provider Business Mailing Address State Name:
VA
Provider Business Mailing Address Postal Code:
23226-1926
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
804-282-8082
Provider Business Mailing Address Fax Number:
317-278-9905

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
5855 BREMO RD STE 100
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
RICHMOND
Provider Business Practice Location Address State Name:
VA
Provider Business Practice Location Address Postal Code:
23226-1926
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
804-282-8082
Provider Business Practice Location Address Fax Number:
317-278-9905
Provider Enumeration Date:
10/03/2006

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 363LN0000X , with the licence number:  71001785 , registered in the state of IN ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 363LN0000X , with the licence number: AP30005699 , registered in the state of WA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 363LN0000X , with the licence number: 28077877 , registered in the state of IN ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 363LN0000X , with the licence number: 0017144265 , registered in the state of VA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 9630104 , issued by the state of ( WA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 200277520 , issued by the state of ( IN ) . This identifiers is of the category "MEDICAID".